Cardiac venous system mapping for ventricular arrhythmia localization

Figures

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  Figure 1. Cardiac venous system anatomy. The top images show the anatomy as seen from typical anatomic views of the anterior and posterolateral cardiac surfaces. In the bottom images, the anatomy is viewed from standard fluoroscopic angles, delineating the expected course for the major epicardial veins. AIV = anterior interventricular vein; CS = coronary sinus; GCV = great cardiac vein; LAO = left anterior oblique; RAO = right anterior oblique.

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  Figure 2. Triangulation approach to mapping of left ventricular (LV) ostial ventricular arrythmias. A, B: Coronary sinus (CS) venography in left anterior oblique and right anterior oblique projections. C, D: A 4-F duo-decapolar catheter (Map-iT) is placed at the great cardiac vein (GCV)/anterior interventricular vein (AIV) to record epicardial activation, a 2-F decapolar catheter (EPstar [EPS]) is positioned into an annular LV vein to assess the intramural space, and an ablation catheter is advanced into the LV via retrograde aortic approach to map the LV endocardium. In this case, an additional decapolar catheter (DecaNav) is located in the right ventricular outflow tract to map the right side of the septum. Abl = ablation catheter; ALV = anterolateral vein; AnV = annular vein; MCV = middle cardiac vein; PLV = posterolateral vein; S1 = first septal vein.

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  Figure 3. MCV mapping. A 12-lead ECG of the clinical VT shows a LBBB pattern with left superior axis, reverse V2 pattern break and QS in inferior leads, consistent with an epicardial exit (A). A multipolar catheter (MAPit) advanced into the MCV showed diastolic signals in the distal portion of the vein and percutaneous epicardial access was obtained (B). Voltage mapping showed a small area of epicardial scar adjacent to the MCV catheter (C), where sharp diastolic electrograms were recorded during VT (red arrows) (D). After a coronary angiogram showed a safe distance from the RCA, ablation resulted in immediate VT termination.

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  Figure 4. Intramural PVC. The 12-lead ECG shows a LBBB morphology with right superior axis and V3 transition (A). After comprehensive mapping of the coronary venous system, earliest ventricular activation is recorded from a multipolar catheter (EPStar) positioned inside an annular vein (earlier than LV endocardium and GCV/AIV), confirming an intramural origin (B). An ablation catheter is advanced into the LV via retrograde aortic approach and placed immediately adjacent to the earliest pole of the multipolar catheter (C, D). Ablation at this site guided by anatomy terminates the PVC despite relatively later activation time (E).

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  Figure 5. Our approach to mapping and ablation of intramural septal ventricular arrhythmias. AIV = anterior interventricular vein; ECG = electrocardiogram; GCV = great cardiac vein; LV = left ventricular; LVS = left ventricular septum; MCV = middle cardiac vein; PVC = premature ventricular complex; RF = radiofrequency; RV = right ventricle; VT = ventricular tachycardia.